What do you do when parent refuses to pick up student for a pink eye?

Jolie, BSN · Sep 25, 2011

I mean no disrespect, katy, but I don't think I would have handled the situation the way you did.

As I understand it, the child presented with a questionable looking eye on Tuesday. Since Mom declined to pick the child up at that time, you observed for the rest of the day and it improved. On Wednesday, it was fine. On Thursday, it was looking red again and you notified the parents that the child would be excluded from school on Friday unless she presented a doctor's note. On Friday, she came in anyway and her eye looked fine. You are concerned that the mom may have used unauthorized medicine at home to enable her child to come to school and are frustrated that you have had difficulty reaching Mom due to phone changes.

First off, I understand your frustration. Eye irritation can be difficult to assess. And not being able to reach a parent or feeling that a parent is trying to undermine you is not pleasant. But I believe the parental issues may have arisen from a potentially unnecessary decision to exclude the child.

I've attached references to a few good articles about assessing eye irritation and guidelines for excluding from school. As a school nurse, this was one of the most difficult things for me to learn to assess, but I gained confidence with time, and found that it was rarely necessary to send a child home for this reason.

Given the improvement that you saw over the first 2 days and the reappearance of redness which went away quickly overnight, I question whether this child had an infectious process at all. Even if she did, I seriously doubt that one night of eye drops would have cleared things up so convincingly. I suspect that her irritation was due to another cause, such as allergies, a foreign body, sensitivity to something in the environment (such as smoke, chlorinated pool water, chemicals at home or in the art room, etc.)

When I have a child with eye irritation, I usually ask what their eye was like immediately upon waking that morning. If they tell me that they had lots of goop and had to pull their eye open, then red flags go up. But that is rarely the case. Is just one eye, or both affected? Does the child have any other s/s illness or allergies such as fever, runny nose, sore throat, cough, ear pain, palpable lymph nodes, rash? Is there significant purulent drainage, or just watery eyes? Does the eye hurt, sting, burn? Have any other family members or classmates had eye infections recently? If I have any doubt about whether the child's eye is infectious or not, I'll give them a warm washcloth and have them clean the eye thoroughly. Then I have them rest for 15 minutes with a cool cloth over their eyes. If I see improvement with the cool compress and no further drainage, I'll send them back to class with instructions to wash their hands frequently and keep them away from their face. The teachers will let me know if drainage recurs or if the child continues to have a problem.

Most of the time, eye irritation that I see has nothing to do with infection. When it does, our school policy allows for exclusion until treatment has been in progress for 24 hours and/or the child can control himself from contaminating surfaces.

I had a situation with one family that drove home the importance of excluding only when absolutely necessary:

I was at the DMV on my day off when a mom from school came in, and had her elementary school aged daughter with her. She stated that Janie had been sent home the previous afternoon by the secretary (who didn't bother to call a nurse to assess the child) due to "pinkeye." It was the Dad's afternoon to pick up the children and keep them overnight, so he got her early, but didn't think that a doctor's visit was warranted. (He was right.) Unfortunately, the secretary caught the girl on the way into school the next morning and sent her home, since her eyes were still pink. She wouldn't be allowed back without a doctor's note. Mom called her pediatrician, a solo practitioner, only to find that she was off that day. There was another office covering for her patients, but she would be charged a new patient rate for an urgent visit if she went in that day. Mom told me that she had taken the children swimming 2 nights previous and that the pool was over-chlorinated. she said that all of the kids had come out with very red eyes, but the others had improved more quickly. I checked Janie and found that she had no drainage, no sensitivity to light, no other s/s of illness, and realized that she was old enough and cooperative enough to follow instructions to keep her hands clean and not to touch her face. I called the school and explained the situation, assuring them that I would take responsibility for allowing Janie back to school. Mom took her to her own doctor the next day who confirmed that the child was NOT contagious.

I think the secretary meant well, but she lacked the assessment skills necessary to evaluate the child and should have called a nurse. As it was, the family faced a significant and unnecessary doctor bill if they had taken the child to the doctor that day. We do well to try and understand these factors and only insist on doctor's notes when there is no other way to ensure a child's well-being.

http://www.medscape.com/viewarticle/522242

Conjunctivitis caused by adenoviruses or enteroviruses is self-limiting and requires no therapy other than careful hand washing to minimize spread to others. Artificial tears, topical antihistamines, and cool compresses may provide symptomatic relief.[3] Bacterial conjunctivitis is typically treated with one of a variety of prescription ocular antibiotics. The AAO guidelines state that this infection, too, may be self-limiting and not require antibiotics, though they caution that this practice is only approved for adults.[2]

The difficulty lies in identifying the child, often younger than 5 years old, who develops bacterial conjunctivitis as a secondary complication of a primary viral infection. For this reason, many providers opt to treat all children who present with a clinical picture consistent with conjunctivitis. Treatment with topical antibiotics shortens the course of infection and may allow a child to return to school earlier. However, a recent British study of over 300 children found that treatment with chloramphenicol or placebo resulted in virtually identical clinical cure rates and argued that most children with conjunctivitis do not require treatment.[6]

http://www.medscape.com/viewarticle/522242

SchoolNurseChristine · Sep 25, 2011

Thank you Jolie for your post! :heartbeat I am a relatively new school nurse (started in February last school year) and have found this to be a difficult thing to assess. Its especially difficult when a teacher wants to send the student home and I know there is no reason for it.

Flare, ASN, BSN · Sep 26, 2011

Jolie pretty much said it all

As an aside - we once had an opthamalogist come by to speak to the SNs in my district. We asked him if he knew any tricks to tell for sure if it's pink eye or just allergy - he said no.

Purple_Scrubs, BSN, RN · Sep 26, 2011

Eyes are so hard to assess. Even after 4 years of this I still second guess myself. Sometimes you can clearly see that the conjunctiva is what is pink, other times it will simply be bloodshot with a clear conjunctiva, but it can be really tricky to tell. I also use the test of asking what it was like when the student first woke up. If they do not describe sticky, gooey eyes or drainage, and I am not seeing drainage, then I generally take a wait and see approach.

I also check their health histories to see if they have any history of allergies or allergic conjunctivitis, and I will take to the parent about history of allergies before I make the decision on whether to refer or not.

And still, sometimes I am wrong :) It happens!

katynurs22 · Sep 26, 2011

Thanks for your reply and recommendations. Pink eye is really hard to assess to me, especially as a fairly new school nurse.

I don't know what to believe sometimes. My school is a title 1;it's in a very low income neighborhood and getting the kids to see a doctor has been an issue here. We have lots of assistance programs, such as local neighborhood clinic offering free first time visits and assistance ministries that help to pay for doctor's visits.

I have seen frequent medical neglect and how some parents choose folk medicine healers instead of medical doctors. Folk medicine is okay for some things but not for sprains and possible fractures.

I find myself jumping to conclusions about the parents , especially since I've had an encounter with this mother already.

I don't know if she treated her herself , but the kiddos eye is clear and no one else has it in her classroom !

mc3, ASN, RN · Sep 27, 2011

Our district tries to keep it fairly simple. It says if there's any suspicion of pink-eye, it must be checked out by an MD. If positive, child cannot return to school without starting tx, and an MD note. I always ask the child if his eye had a lot of "guck" in it when they woke up, and if they told Mom. I also ask how long this has been going on. If no "guck" and it "just started", I check their medical info sheet, and 99.9% of them have allergies. So, I give them a cool compress and rest a bit. If they don't have allergies, and have sticky drainage, our protocol is to call the parent and tell them our findings and protocol. I don't try to determine if it's bacterial or viral - that's for the MD to decide. If I really believe it is conjunctivitis and a parent is resistant, I ask the principal to call parent' - she has a wonderful way of persuading parents to take their child to the doctors if we believe they have a problem. (I'm so lucky to have her!!!) We're also a Title 1 school but have have a county free clinic if need be.

mc3

:nurse:

P.S. What drops do you have in the clinic that you gave to the child? Were they prescribed, or just an eye wash? We are not allowed to keep any idea drops or washes. Even if they were prescribed, we're not allowed to administer. This is an elementary school, but this policy is county-wide and includes all schools.

katynurs22 · Sep 30, 2011

Bausch & Lomb lubricant drops, they are the only district approved eye drops

Artistyc1 · Sep 30, 2011

As many cases of pinkeye are caused by the same virus that causes the common cold, my district does not exclude for pinkeye. Our district pediatrician states that as viral pinkeye, bacterial pinkeye, and allergic pinkeye are difficult to discern from one another, the physicians will prescribe drops or ointment just to keep the school nurses happy! And that is even though most types of pinkeye will resolve with or without treatment of any sort.

If it is a very young child that cannot be expected to keep his hands away from his face, and to keep his hands clean, we may send them home. If the kid is truly miserable, of course we will call the parent to bring the child to their physician. Some children will appear to have pinkeye, even though they really have sinus infections.

We have had this policy for many years now, and have had no problems arise from it.

For many children, staying in school whenever possible is by far the best thing- most of our families are very low income, transient, etc.- our children miss a lot of school at the best of times.